Provider Demographics
NPI:1811233984
Name:MAYLIN GONZALEZ OD AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:MAYLIN GONZALEZ OD AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:424-208-3107
Mailing Address - Street 1:12222 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1173
Mailing Address - Country:US
Mailing Address - Phone:424-208-3107
Mailing Address - Fax:424-208-3065
Practice Address - Street 1:12222 WILSHIRE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1173
Practice Address - Country:US
Practice Address - Phone:424-208-3107
Practice Address - Fax:424-208-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty